A pregnant client is admitted to the labor and delivery unit for a scheduled elective cesarean birth. The client signed the surgical consent form in the provider's office last week. As the nurse prepares to administer a prescribed preoperative oral antacid, the client states, 'I've changed my mind. I am not having surgery and want to try delivering naturally.' Arrange the following nursing actions in the correct priority sequence. (Place the first action at the top and the last action at the bottom.)
- 1Withhold the preoperative medication and cease all surgical preparations.
- 2Explore the client's concerns and reasons for changing the birth plan.
- 3Contact the obstetrician to report that the client is withdrawing surgical consent.
- 4Maintain ongoing maternal and fetal monitoring while awaiting the provider.
- 5Document the client's verbatim statements and the provider notification in the medical record.
Answer
The correct sequence is to first withhold the medication, then explore the client's concerns, contact the obstetrician, maintain ongoing monitoring, and finally document the event.
When a client revokes informed consent, the nurse's immediate priority is to stop any interventions related to the procedure to respect client autonomy. Second, the nurse should use therapeutic communication to explore the client's underlying concerns. Third, the nurse must notify the healthcare provider, as it is the provider's legal responsibility to discuss the medical risks of refusal and alternative options. Fourth, while awaiting the provider, the nurse must continue standard monitoring to ensure maternal and fetal safety. Finally, all actions, verbatim client statements, and provider notifications must be thoroughly documented in the legal medical record.
Step-by-Step Solution
Key Concept
A competent client has the right to revoke informed consent at any time prior to a procedure. The nurse's role is to halt the procedure, assess the client's concerns, notify the healthcare provider, ensure ongoing safety, and thoroughly document the event.